Who should get a COVID-19 vaccine first? There are new recommendations in Canada

TORONTO — Essential workers and others who face increased risks related to COVID-19 should be vaccinated against the disease before everyone else, according to new recommendations submitted to the federal government.

Although Prime Minister Justin Trudeau has said that all Canadians will be able to get an approved COVID-19 vaccine for free, the immunizations will not happen all at once. It is expected that several months will elapse between the first doses of the vaccine being made available and a full rollout to everyone who wants to be immunized.

This leads to an obvious question: Which Canadians or groups of Canadians should be prioritized? Who should get to move to the front of the line, and who should have to wait?

One group of medical, pharmaceutical and public health experts is used to considering these questions, although not on this scale. The National Advisory Committee on Immunization (NACI) is a long-established body that makes recommendations to the Public Health Agency of Canada on vaccines and vaccine-related issues. They’ve weighed in on vaccines covering more than a dozen different diseases over the past decades, and their advice helped create the push to expand human papillomavirus vaccine programs to include boys.

Now they’ve turned their attention to COVID-19. On Tuesday, they issued their first recommendations on target populations for COVID-19 immunization.

NACI recommends prioritizing four specific groups:

  • ‘Those at high risk of severe illness and death from COVID-19,’ including older populations and other groups to be determined
  • ‘Those most likely to transmit COVID-19 to those at high risk of severe illness and death from COVID-19 and workers essential to maintaining the COVID-19 response,’ including those who live with members of the first group, health-care workers, personal care workers and caregivers who work with seniors
  • ‘Those contributing to the maintenance of other essential services for the functioning of society,’ including front-line workers such as police officers, firefighters and grocery store staff
  • ‘Those whose living or working conditions put them at elevated risk of infection and where infection could have disproportionate consequences, including Indigenous communities,’ including those who live or work in settings where it is difficult to distance and where it is difficult to access health care

The NACI report does not say any of these groups should be prioritized over any of the others, and does not suggest the examples it gives are a full list of who should be included in any of the groups.

It does recommend that decisions around who is vaccinated first among the prioritized groups be made based on factors including vaccine supply, COVID-19 conditions in Canada at the time, the results of a risk-benefit analysis, and characteristics of the vaccine itself.

Dr. Theresa Tam, Canada’s chief public health officer, said Monday in a statement that the NACI recommendations are “just the starting point” when it comes to determining which groups to prioritize for vaccination.

“We know Canadians will understand the need to prioritize some groups during the early weeks of COVID-19 vaccine roll-out until there is enough vaccine for everyone who wants it,” she said.

Tam said she is “cautiously optimistic” that a vaccine could be approved for use in Canada by March 2021.


The recommendations are based in part on separate surveys of 74 expert stakeholders and more than 2,100 members of the public.

When given four competing pandemic priorities, respondents to both surveys ranked them in the same order of importance: protect the most vulnerable, then protect the capacity of the health-care system, then minimize the spread of the virus, then protect critical infrastructure.

However, it is less clear from the survey data if there is public support for prioritizing all of the recommended groups. While a majority of respondents were in favour of giving first access to those with underlying medical conditions and the elderly, and there was also notable support for prioritizing health-care workers, all other groups – including essential workers and those who work in long-term care homes – had less than 20 per cent of respondents in favour of prioritization.

The government’s survey also found that willingness to get an effective COVID-19 vaccine appears to be decreasing. While 71 per cent of respondents said in April that they would get a vaccine, that number was down to 61 per cent in August.

In part because of this, NACI recommends that governments do more to promote the benefits of vaccines in general and a COVID-19 vaccine specifically, once one is approved for use.

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